Although Tanzania has made significant progress in reducing maternal, neonatal and child mortality, the number of deaths remains stubbornly high at 556 per 100,000 live births and 25 per 1,000 births respectively (MoHCDGEC). Evidence indicates that the majority of these deaths are correlated with home births – nearly half of which take place without the assistance of a skilled birth attendant. For births in hospitals and other health facilities, inadequate equipment and clinical training often undermine quality of care. To help address these problems, VSO designed pilots to test a range of clinical tools for maternal and neonatal health and it then packaged them for use at the district level. The interventions included setting up low-cost Neonatal Intensive Care Units (NICUs), a Newborn Triage Checklist (NTC) that can be used by low-level health-care workers to identify at-risk infants, and the introduction of Vscans – portable, solar-powered ultrasound devices that screen pregnant women to identify those at risk.
The ACT! project aimed to reduce maternal and neonatal deaths in Lindi and Mtwara Regions by 30 per cent. ACT! introduced the intervention package to eight district hospitals, with a view to reaching 630 health-care workers (HCWs) and 150,000 mothers and their new babies. Due to a severe shortage of qualified HCWs in Tanzania, responsibility for care often falls to underqualified lower-level HCWs in primary health-care facilities such as dispensaries and health centres. ACT! trained these HCWs to deliver quality and basic maternal and neonatal services such as newborn resuscitation, kangaroo mother care (KMC) and the use of NTC and Vscans. The project also provided capacity building to mid-level HCWs and helped build the skills of local volunteer community health workers (CHWs) in order to increase referrals and create demand for services through community awareness. CHWs were also trained to collect mobile numbers of the pregnant women in order to send SMS appointment reminders and health messages and record the number of women attending antenatal clinics (ANCs).
- The evidence from Health Management Information Systems (HMIS) data shows that survival rates for the neonates in the project’s target facilities increased from 35 per cent at the start of the project to 85 per cent at the end. Maternal deaths declined from 97 deaths to 52 deaths in the same period.
- Use of Vscans at lower-level facilities brought the services closer to the mothers. Currently, 90 per cent of pregnant women attending ANCs in targeted health facilities are screened for pregnancy complications every month.
- 637 HCWs were trained to use the NTC.
- A total of 80,892 (18,237 in Lindi and 62,655 in Mtwara) pregnant women and mothers were registered on the SMS platform.
- The project contributed to an increase of ANC visits from 23 per cent to 30 per cent in Lindi and from 21 per cent to 57 per cent in Mtwara (HMIS).
Test a new technological component before including it in scale-up: Health facilities experienced inconsistent deployment of the SMS system. It was challenging for facility staff to adopt the new system while collecting phone numbers, as it added to the time spent interacting with clients.
Deploying new technology to remote facilities at scale requires careful planning: Inconsistent battery performance and hard-to-find replacements limited the length of outreach trips in remote areas. At the same time, a lack of experienced technicians who could undertake timely repairs led to general equipment breakdowns. Hardware rollouts need to include plans for systematic adoption, and consideration should be given to investing in partnerships to provide the required technical support.
Funding is intrinsically linked to the success of scaling a model sustainably: Expenses related to the renovation of the NICU and the purchase of neonatal equipment are investments that go beyond the original low-tech, low-cost concept of the innovation. These costs have been difficult for some facilities to absorb. Implementers could consider phasing-in these components to allow for cost planning or the identification of complementary funding.
Develop incentives for volunteer CHWs: Only 60 per cent of the trained volunteer CHWs provided SMS information or conducted follow-up visits to pregnant women and mothers of the newborn in targeted health facilities. Long-term engagement of volunteer CHWs requires some form of incentive to keep them motivated.
Gender equity and social inclusion
The project empowered mothers to care for their babies during their stay in the NICU by encouraging them to feed, bathe and observe them for any changes in their condition. Eighty per cent of the staff trained to use the Vscan were women. Female clinicians attested to feeling more empowered after the training provided by VSO and said their confidence had improved as a result. One female nurse commented that since the nurses working on the NICU had received training, they received more cooperation from the doctors in the hospital, which in turn has improved health outcomes for babies.
Principles for digital development
Be collaborative: The success of ACT! was due in part to strong partnership and good relationship with the regional and district health management teams (RHMT and CHMT), GE Healthcare and partner hospitals. Regional and community health management teams actively participated in the design and implementation of ACT! and subsequently took ownership of the project in their areas.
Design for scale: VSO took a number of steps to ensure that the ACT! model was prepared for scale-up. This included (i) strengthening the referral systems between health-care workers carrying out Vscans and those working at lower-level facilities; (ii) placing highly skilled volunteers in facilities to provide onsite supervision and on-the-job training; and (iii) introducing a supportive supervision process through which teams could improve performance by undertaking reviews as a group.
The ACT! model has been widely accepted as an effective approach by the Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDGEC), RHMT and CHMT and other development partners because of its proven impact on improving maternal and neonatal health outcomes. The project’s success has led to discussions with MoHCDGEC on introducing NICUs to all district hospitals and scaling-up Vscans to all primary health-care facilities throughout Tanzania. VSO has received additional funding to scale up the ACT! package to other facilities in Lindi and Mtwara Regions, and more funding is in the pipeline to scale up the innovations in the lake zones of Tanzania. Partners RHMT and CHMT have also allocated financial and human resources to help sustain the innovation.